Management of Active Tuberculosis
BETH POTTER, M.D., KIRSTEN RINDFLEISCH, M.D., University of Wisconsin Medical School, Madison, Wisconsin
CONNIE K. KRAUS, PHARM.D., University of Wisconsin School of Pharmacy, Madison, Wisconsin
Nearly one third of the world’s population is infected with Mycobacterium tuberculosis.1 More than one half of all infections occur in China, Southeast Asia, and the Indian subcontinent; the highest per capita incidence occurs in sub-Saharan Africa.2 In the United States, the incidence of active tuberculosis has decreased steadily since 1992.3 However, the rate of decline has slowed in the past two years.4 Some states and urban centers still report increases in infections, and disparities in incidence and morbidity persist among certain high-risk groups.
Screening and Primary Prevention
The U.S. Preventive Services Task Force5 recommends routine screening for tuberculosis in high-risk populations (Table 1 5). The goal of his recommendation
is to identify persons at significant risk for progressing to active disease. A validated riskassessment questionnaire may be used to identify children
who are likely to benefit from screening (Table 2 6). Primary prevention efforts have focused on the bacille Calmette-Guérin (BCG) vaccine, a live vaccine derived from an attenuated strain of Mycobacterium bovis.
Although BCG vaccine is used commonly in many parts of the world, few data support its effectiveness in reducing tuberculosisrelated morbidity and mortality in the general population. However, vaccination does reduce the occurrence of severe (e.g., meningeal) and disseminated forms of tuberculosis in young children. In the United States, vaccination may be considered for children
with continuous and unavoidable exposure to adults with inadequately treated or multidrug-resistant active disease.7 The decision to vaccinate should be made in consultation with local tuberculosis control programs.
Diagnosis
The diagnosis of active tuberculosis begins with a high index of suspicion for disease. A positive acid-fast bacillus (AFB) smear or positive culture for M. tuberculosis confirms active disease. However, if the suspicion for active disease is high enough, treatment should begin without waiting for a final diagnosis.
Although the overall incidence of tuberculosis has been declining in the United States, it remains an important public health concern, particularly among immigrants, homeless persons, and persons infected with human immunodeficiency virus. Patients who present with symptoms of active tuberculosis (e.g., cough, weight loss, or malaise with known exposure to the disease) should be evaluated. Three induced sputum samples for acid-fast bacillus smear and culture should be obtained from patients with findings of tuberculosis or suspicion for active disease.
If the patient has manifestations of extrapulmonary tuberculosis, smears and cultures should be obtained from these sites. Most patients with active tuberculosis should be treated initially with isoniazid, rifampin, pyrazinamide, and ethambutol for eight weeks, followed by 18 weeks of treatment with isoniazid and rifampin if needed. Repeat cultures should be performed after the initial eight-week treatment.
(Am Fam Physician 2005;72:2225-32, 2235. Copyright © 2005 American
Academy of Family Physicians.)
http://www.aafp.org/afp/2005/1201/p2225.pdf
Showing posts with label tuberculosis treatment results. Show all posts
Showing posts with label tuberculosis treatment results. Show all posts
Sunday, 12 September 2010
TUBERCULOSIS: Multidrug-resistant tuberculosis in Europe: Managed or mismanaged?
07.09.2010
The European Respiratory Society as well as researchers from the World Health Organization (WHO) and the European Centre for Disease Prevention and Control (ECDC) are warning against the dangers of multidrug-resistant TB.
Every year, over 9 million new cases of TB are reported worldwide, with almost 2 million deaths. To make matters worse, the threat of multidrug-resistant bacilli has emerged, making the disease more expensive and difficult to treat.
In 2010, the World Health Organization (WHO) reported an unexpectedly high prevalence of multidrug-resistant tuberculosis with peaks of 25% or more among new cases of TB in some settings. At present, an estimated 5% of the more than 9 million people who develop TB around the world every year are infected with an MDR-TB strain, i.e. a strain that is resistant to (at least) the two most powerful anti-TB drugs currently available, isoniazid and rifampicin. During a joint press conference at the 20th Annual Congress of the European Respiratory Society, experts in the field of tuberculosis will address current challenges in the management of the disease, such as TB/HIV co-infection and the rise of resistant TB strains as well as present an European TB research network, TBNET, aimed at advancing science, clinical research, training, policy development and public health.“TB is a global problem that needs to be dealt with by the international community,” urges Professor Giovanni Battista Migliori, ERS Assembly Head of Respiratory Infections and Director of the WHO Collaborating Centre for TB and Lung Disease, Tradate, Italy.TBNET is an ERS-supported Clinical Research Collaboration (CRC) in the area of tuberculosis research, working in close collaboration with WHO and ECDC. The main areas of focus are the development of improved diagnostic methods and new drugs as well as the prevention and control of drug-resistant TB.“One of the biggest problems in most European countries is that treatment success rates are far below the 85% target set by the WHO World Health Assembly, thereby promoting resistance to common anti-tuberculosis drugs” explains Dr Davide Manissero, Head of Section Respiratory Tract Infections and Tuberculosis Programme Coordinator at the ECDC, Stockholm, Sweden. “Part of the problem is that treatment for multidrug-resistant TB takes substantially longer than for uncomplicated TB; treatment of MDR requires up to 24 months` worth of treatment. The drugs needed are less effective than the first-line drugs for the treatment of drug-susceptible TB and cause more side effects,” says Dr Manissero. For multidrug-resistant TB, the treatment success rate is extremely low (31%). A further threat is extensively multidrug-resistant TB (XDR-TB), defined as MDR-TB that is additionally resistant to any of the fluoroquinolones and any of the three injectable second-line anti-TB drugs, amikacin, kanamycin, and capreomycin.The M/XDR-TB threat is further aggravated by the poor outcomes of this group of patients. In a cohort of 1,100 patients only 30.9% of those who started treatment in 2006 (2006 cohort) were successfully treated in the EU/EEA. A high percentage (13.2%) of these MDR-TB cases defaulted from treatment, increasing the risk for XDR-TB.The latest figures on multidrug-resistant tuberculosis show about 440,000 cases of MDR-TB, causing at least 150,000 deaths. XDR-TB has been reported officially from 58 countries as of March 2010, explains Professor Mario Raviglione, Director, Stop TB Department, WHO, Geneva. “Of all cases of TB, over a million occurred among people living with HIV/AIDS and nearly half a million were fatal.”It is unclear whether HIV infection is a risk factor for drug-resistant or MDR-TB. Known factors that can promote the development of resistance include malabsorption, drug intolerance, drug interactions, and noncompliance among intravenous drug abusers.Dr Raviglione concludes: “Proper TB control based on early and rapid detection and adequate treatment until cure must be in place everywhere to interrupt transmission, avert deaths, and prevent MDR-TB.”
http://www.innovations-report.de/html/berichte/medizin_gesundheit/multidrug_resistant_tuberculosis_europe_managed_161168.html?
The European Respiratory Society as well as researchers from the World Health Organization (WHO) and the European Centre for Disease Prevention and Control (ECDC) are warning against the dangers of multidrug-resistant TB.
Every year, over 9 million new cases of TB are reported worldwide, with almost 2 million deaths. To make matters worse, the threat of multidrug-resistant bacilli has emerged, making the disease more expensive and difficult to treat.
In 2010, the World Health Organization (WHO) reported an unexpectedly high prevalence of multidrug-resistant tuberculosis with peaks of 25% or more among new cases of TB in some settings. At present, an estimated 5% of the more than 9 million people who develop TB around the world every year are infected with an MDR-TB strain, i.e. a strain that is resistant to (at least) the two most powerful anti-TB drugs currently available, isoniazid and rifampicin. During a joint press conference at the 20th Annual Congress of the European Respiratory Society, experts in the field of tuberculosis will address current challenges in the management of the disease, such as TB/HIV co-infection and the rise of resistant TB strains as well as present an European TB research network, TBNET, aimed at advancing science, clinical research, training, policy development and public health.“TB is a global problem that needs to be dealt with by the international community,” urges Professor Giovanni Battista Migliori, ERS Assembly Head of Respiratory Infections and Director of the WHO Collaborating Centre for TB and Lung Disease, Tradate, Italy.TBNET is an ERS-supported Clinical Research Collaboration (CRC) in the area of tuberculosis research, working in close collaboration with WHO and ECDC. The main areas of focus are the development of improved diagnostic methods and new drugs as well as the prevention and control of drug-resistant TB.“One of the biggest problems in most European countries is that treatment success rates are far below the 85% target set by the WHO World Health Assembly, thereby promoting resistance to common anti-tuberculosis drugs” explains Dr Davide Manissero, Head of Section Respiratory Tract Infections and Tuberculosis Programme Coordinator at the ECDC, Stockholm, Sweden. “Part of the problem is that treatment for multidrug-resistant TB takes substantially longer than for uncomplicated TB; treatment of MDR requires up to 24 months` worth of treatment. The drugs needed are less effective than the first-line drugs for the treatment of drug-susceptible TB and cause more side effects,” says Dr Manissero. For multidrug-resistant TB, the treatment success rate is extremely low (31%). A further threat is extensively multidrug-resistant TB (XDR-TB), defined as MDR-TB that is additionally resistant to any of the fluoroquinolones and any of the three injectable second-line anti-TB drugs, amikacin, kanamycin, and capreomycin.The M/XDR-TB threat is further aggravated by the poor outcomes of this group of patients. In a cohort of 1,100 patients only 30.9% of those who started treatment in 2006 (2006 cohort) were successfully treated in the EU/EEA. A high percentage (13.2%) of these MDR-TB cases defaulted from treatment, increasing the risk for XDR-TB.The latest figures on multidrug-resistant tuberculosis show about 440,000 cases of MDR-TB, causing at least 150,000 deaths. XDR-TB has been reported officially from 58 countries as of March 2010, explains Professor Mario Raviglione, Director, Stop TB Department, WHO, Geneva. “Of all cases of TB, over a million occurred among people living with HIV/AIDS and nearly half a million were fatal.”It is unclear whether HIV infection is a risk factor for drug-resistant or MDR-TB. Known factors that can promote the development of resistance include malabsorption, drug intolerance, drug interactions, and noncompliance among intravenous drug abusers.Dr Raviglione concludes: “Proper TB control based on early and rapid detection and adequate treatment until cure must be in place everywhere to interrupt transmission, avert deaths, and prevent MDR-TB.”
http://www.innovations-report.de/html/berichte/medizin_gesundheit/multidrug_resistant_tuberculosis_europe_managed_161168.html?
Saturday, 21 August 2010
TUBERCULOSIS: Tuberculosis Management by Private Practitioners in Mumbai, India
A study conducted in Mumbai two decades ago revealed the extent of inappropriate tuberculosis (TB) management practices of private practitioners. Over the years, India's national TB programme has made significant progress in TB control. Efforts to engage private practitioners have also been made with several successful documented public-private mix initiatives in place.
To study prescribing practices of private practitioners in the treatment of tuberculosis, two decades after a similar study conducted in the same geographical area revealed dismal results.
Survey questionnaire administered to practicing general practitioners attending a continuing medical education programme.
The participating practitioners had never been approached or oriented by the local TB programme. Only 6 of the 106 respondents wrote a prescription with a correct drug regimen. 106 doctors prescribed 63 different drug regimens. There was tendency to over treat with more drugs for longer durations. Only 3 of the 106 respondents could write an appropriate prescription for treatment of multidrug-resistant TB.
With a vast majority of private practitioners unable to provide a correct prescription for treating TB and not approached by the national TB programme, little seems to have changed over the years. Strategies to control TB through public sector health services will have little impact if inappropriate management of TB patients in private clinics continues unabated. Large scale implementation of public-private mix approaches should be a top priority for the programme. Ignoring the private sector could worsen the epidemic of multidrug-resistant and extensively drug-resistant forms of TB.
Mumbai, India. A study conducted in Mumbai two decades ago revealed the extent of inappropriate tuberculosis (TB) management practices of private practitioners. Over the years, India's national TB programme has made significant progress in TB control. Efforts to engage private practitioners have also been made with several successful documented public-private mix initiatives in place.
Objective
To study prescribing practices of private practitioners in the treatment of tuberculosis, two decades after a similar study conducted in the same geographical area revealed dismal results.
Methods
Survey questionnaire administered to practicing general practitioners attending a continuing medical education programme.
Results
The participating practitioners had never been approached or oriented by the local TB programme. Only 6 of the 106 respondents wrote a prescription with a correct drug regimen. 106 doctors prescribed 63 different drug regimens. There was tendency to over treat with more drugs for longer durations. Only 3 of the 106 respondents could write an appropriate prescription for treatment of multidrug-resistant TB.
Conclusions
With a vast majority of private practitioners unable to provide a correct prescription for treating TB and not approached by the national TB programme, little seems to have changed over the years. Strategies to control TB through public sector health services will have little impact if inappropriate management of TB patients in private clinics continues unabated. Large scale implementation of public-private mix approaches should be a top priority for the programme. Ignoring the private sector could worsen the epidemic of multidrug-resistant and extensively drug-resistant forms of TB.
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0012023?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+plosone%2FPLoSONE+%28PLoS+ONE+Alerts%3A+New+Articles%29
To study prescribing practices of private practitioners in the treatment of tuberculosis, two decades after a similar study conducted in the same geographical area revealed dismal results.
Survey questionnaire administered to practicing general practitioners attending a continuing medical education programme.
The participating practitioners had never been approached or oriented by the local TB programme. Only 6 of the 106 respondents wrote a prescription with a correct drug regimen. 106 doctors prescribed 63 different drug regimens. There was tendency to over treat with more drugs for longer durations. Only 3 of the 106 respondents could write an appropriate prescription for treatment of multidrug-resistant TB.
With a vast majority of private practitioners unable to provide a correct prescription for treating TB and not approached by the national TB programme, little seems to have changed over the years. Strategies to control TB through public sector health services will have little impact if inappropriate management of TB patients in private clinics continues unabated. Large scale implementation of public-private mix approaches should be a top priority for the programme. Ignoring the private sector could worsen the epidemic of multidrug-resistant and extensively drug-resistant forms of TB.
Mumbai, India. A study conducted in Mumbai two decades ago revealed the extent of inappropriate tuberculosis (TB) management practices of private practitioners. Over the years, India's national TB programme has made significant progress in TB control. Efforts to engage private practitioners have also been made with several successful documented public-private mix initiatives in place.
Objective
To study prescribing practices of private practitioners in the treatment of tuberculosis, two decades after a similar study conducted in the same geographical area revealed dismal results.
Methods
Survey questionnaire administered to practicing general practitioners attending a continuing medical education programme.
Results
The participating practitioners had never been approached or oriented by the local TB programme. Only 6 of the 106 respondents wrote a prescription with a correct drug regimen. 106 doctors prescribed 63 different drug regimens. There was tendency to over treat with more drugs for longer durations. Only 3 of the 106 respondents could write an appropriate prescription for treatment of multidrug-resistant TB.
Conclusions
With a vast majority of private practitioners unable to provide a correct prescription for treating TB and not approached by the national TB programme, little seems to have changed over the years. Strategies to control TB through public sector health services will have little impact if inappropriate management of TB patients in private clinics continues unabated. Large scale implementation of public-private mix approaches should be a top priority for the programme. Ignoring the private sector could worsen the epidemic of multidrug-resistant and extensively drug-resistant forms of TB.
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0012023?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+plosone%2FPLoSONE+%28PLoS+ONE+Alerts%3A+New+Articles%29
TUBERCULOSIS: Drug Schedule Improves Survival Rate of Those With AIDS and Tuberculosis
People who are near death from a combination of tuberculosis and AIDS are more likely to survive if they get immediate TB treatment, followed two weeks later by antiretroviral drugs for AIDS, doctors are reporting.
Several AIDS specialists said the research, supported by the French and American governments and done over five years in five hospitals in Cambodia, was some of the most important revealed at the international AIDS meeting in Vienna last month. A quarter of all deaths among people with AIDS are caused by tuberculosis.
People with both advanced TB and AIDS present doctors with a dilemma: reviving a depressed immune system with anti-AIDS drugs sometimes touches off such a strong inflammatory response against the tuberculosis in the lungs that the patient is killed. So doctors typically start TB treatment first, followed by AIDS treatment. But when to start the second has largely been guesswork.
The trial, nicknamed Camelia, for “Cambodian Early vs. Late Introduction of Antiretrovirals,” found that among 661 patients, those who started taking AIDS drugs two weeks later were 34 percent more likely to survive than those who waited eight weeks before starting.
“We imagine these findings will make a major impact on mortality due to TB and H.I.V. co-infection globally,” said Prof. Eng Huot, the Cambodian secretary of state for health.
Dr. Wafaa el-Sadr, an AIDS expert at Columbia University, said the treatment had saved lives, and added, “It’s another piece of evidence of the positive effects of H.I.V. treatment.”
http://www.nytimes.com/2010/08/10/health/10glob.html
Several AIDS specialists said the research, supported by the French and American governments and done over five years in five hospitals in Cambodia, was some of the most important revealed at the international AIDS meeting in Vienna last month. A quarter of all deaths among people with AIDS are caused by tuberculosis.
People with both advanced TB and AIDS present doctors with a dilemma: reviving a depressed immune system with anti-AIDS drugs sometimes touches off such a strong inflammatory response against the tuberculosis in the lungs that the patient is killed. So doctors typically start TB treatment first, followed by AIDS treatment. But when to start the second has largely been guesswork.
The trial, nicknamed Camelia, for “Cambodian Early vs. Late Introduction of Antiretrovirals,” found that among 661 patients, those who started taking AIDS drugs two weeks later were 34 percent more likely to survive than those who waited eight weeks before starting.
“We imagine these findings will make a major impact on mortality due to TB and H.I.V. co-infection globally,” said Prof. Eng Huot, the Cambodian secretary of state for health.
Dr. Wafaa el-Sadr, an AIDS expert at Columbia University, said the treatment had saved lives, and added, “It’s another piece of evidence of the positive effects of H.I.V. treatment.”
http://www.nytimes.com/2010/08/10/health/10glob.html
Thursday, 12 August 2010
TUBERCULOSIS: Prolonged Infectiousness of Tuberculosis Patients in a Directly Observed Therapy Short-Course Program with Standardized Therapy.
Background.
Effective tuberculosis control is compromised by a lack of clarity about the timeframe of viable Mycobacterium tuberculosis shedding after treatment initiation under programmatic conditions. This study quantifies time to conversion from smear and culture positivity to negativity in unselected tuberculosis patients receiving standardized therapy in a directly observed therapy short-course (DOTS) program.
Methods.
Longitudinal cohort study following up 93 adults initiating tuberculosis therapy in Lima, Peru. Baseline culture and drug susceptibility tests (DSTs) were performed using the MBBacT, proportion, and microscopic observation drug susceptibility (MODS) methods. Smear microscopy and MODS liquid culture were performed at baseline and weekly for 4 weeks then every other week for 26 weeks.
Results.
Median conversion time from culture positivity to culture negativity of 38.5 days was unaffected by baseline smear status. Patients with fully susceptible tuberculosis had a median time to culture conversion of 37 days; 10% remained culture positive at day 60. Delayed culture conversion was associated with multidrug resistance, regardless of DST method used; non-multidrug resistance as defined by the proportion method and MODS (but not MBBacT) was also associated with delay. Persistent day 60 smear positivity yielded positive and negative predictive values of 67% and 92%, respectively, for detecting multidrug resistance.
Conclusions.
Smear and culture conversion in treated tuberculosis patients takes longer than is conventionally believed, even with fully susceptible disease, and must be accounted for in tuberculosis treatment and prevention programs. Persistent day 60 smear positivity is a poor predictor of multidrug resistance. The industrialized-world convention of universal baseline DST for tuberculosis patients should become the standard of care in multidrug resistance-affected resource-limited settings.
http://medicine.journalfeeds.com/infectious-diseases/clin-infect-dis/prolonged-infectiousness-of-tuberculosis-patients-in-a-directly-observed-therapy-short-course-program-with-standardized-therapy/20100715/
Effective tuberculosis control is compromised by a lack of clarity about the timeframe of viable Mycobacterium tuberculosis shedding after treatment initiation under programmatic conditions. This study quantifies time to conversion from smear and culture positivity to negativity in unselected tuberculosis patients receiving standardized therapy in a directly observed therapy short-course (DOTS) program.
Methods.
Longitudinal cohort study following up 93 adults initiating tuberculosis therapy in Lima, Peru. Baseline culture and drug susceptibility tests (DSTs) were performed using the MBBacT, proportion, and microscopic observation drug susceptibility (MODS) methods. Smear microscopy and MODS liquid culture were performed at baseline and weekly for 4 weeks then every other week for 26 weeks.
Results.
Median conversion time from culture positivity to culture negativity of 38.5 days was unaffected by baseline smear status. Patients with fully susceptible tuberculosis had a median time to culture conversion of 37 days; 10% remained culture positive at day 60. Delayed culture conversion was associated with multidrug resistance, regardless of DST method used; non-multidrug resistance as defined by the proportion method and MODS (but not MBBacT) was also associated with delay. Persistent day 60 smear positivity yielded positive and negative predictive values of 67% and 92%, respectively, for detecting multidrug resistance.
Conclusions.
Smear and culture conversion in treated tuberculosis patients takes longer than is conventionally believed, even with fully susceptible disease, and must be accounted for in tuberculosis treatment and prevention programs. Persistent day 60 smear positivity is a poor predictor of multidrug resistance. The industrialized-world convention of universal baseline DST for tuberculosis patients should become the standard of care in multidrug resistance-affected resource-limited settings.
http://medicine.journalfeeds.com/infectious-diseases/clin-infect-dis/prolonged-infectiousness-of-tuberculosis-patients-in-a-directly-observed-therapy-short-course-program-with-standardized-therapy/20100715/
TUBERCULOSIS: Treatment outcome of extra-pulmonary tuberculosis in Finland
6 July 2010
Background
We investigated the treatments given, the outcome and the patient- and treatment-system dependent factors affecting treatment outcome in a national two-year cohort of culture-verified extra-pulmonary tuberculosis cases in Finland.
Methods
Medical records of all cases in 1995 - 1996 were abstracted to assess treatment and outcome, using the European recommendations for outcome monitoring. For risk factor analysis, outcome was divided into three groups: favourable, death and other unfavourable. Predictors of unfavourable outcome were assessed in univariate and multivariate analysis.
Results
In the study cohort of 276 cases, 116 (42.0%) were men and 160 (58.0%) women. The mean age was 65.7 years. A favourable outcome was achieved in 157/276 (56.9%) cases, consisting of those cured (8.0%) and treatment completed (48.9%). Death was the outcome in 17.4% (48/276) cases, including cases not treated. Other unfavourable outcomes took place in 45 (16.3%) cases. Significant independent risk factors for death in multinomial logistic regression model were male sex, high age, immunosuppression, any other than a pulmonary specialty being responsible at the end of the treatment and other than standard combination of treatment. For other unfavourable treatment outcomes, significant risk factor was treatment with INH + RIF + EMB/SM. Deep site of TB was inversely associated with the risk of other unfavourable outcome.
Conclusions
The proportion of favourable outcome was far below the goal set by the WHO. Age and comorbidities, playing an important role in treatment success, are not available in routine outcome data. Therefore, comparisons between countries should be made in cohort analyses incorporating data on comorbidities.
http://www.biomedcentral.com/1471-2458/10/399
Background
We investigated the treatments given, the outcome and the patient- and treatment-system dependent factors affecting treatment outcome in a national two-year cohort of culture-verified extra-pulmonary tuberculosis cases in Finland.
Methods
Medical records of all cases in 1995 - 1996 were abstracted to assess treatment and outcome, using the European recommendations for outcome monitoring. For risk factor analysis, outcome was divided into three groups: favourable, death and other unfavourable. Predictors of unfavourable outcome were assessed in univariate and multivariate analysis.
Results
In the study cohort of 276 cases, 116 (42.0%) were men and 160 (58.0%) women. The mean age was 65.7 years. A favourable outcome was achieved in 157/276 (56.9%) cases, consisting of those cured (8.0%) and treatment completed (48.9%). Death was the outcome in 17.4% (48/276) cases, including cases not treated. Other unfavourable outcomes took place in 45 (16.3%) cases. Significant independent risk factors for death in multinomial logistic regression model were male sex, high age, immunosuppression, any other than a pulmonary specialty being responsible at the end of the treatment and other than standard combination of treatment. For other unfavourable treatment outcomes, significant risk factor was treatment with INH + RIF + EMB/SM. Deep site of TB was inversely associated with the risk of other unfavourable outcome.
Conclusions
The proportion of favourable outcome was far below the goal set by the WHO. Age and comorbidities, playing an important role in treatment success, are not available in routine outcome data. Therefore, comparisons between countries should be made in cohort analyses incorporating data on comorbidities.
http://www.biomedcentral.com/1471-2458/10/399
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